V865: Right Robotic Adrenalectomy for greater than 5 cm adrenal mass
VideoIntroduction and Objectives
Indications for adrenalectomy include functioning adrenal masses such as aldosteronoma, pheochromocytoma, glucocorticoid-producing adenomas, Cushing’s syndrome, or nonfunctioning adrenal lesions > 5 cm, due to risk of adrenal cortical carcinoma. We present a 71 y/o male who presented with bilateral adrenal masses measuring 8.5 cm on the right and 4 cm on the left. He denied any signs or symptoms of hormonal excess. He reported a 35 lb weight loss over 4 months. Hormonal evaluation was all within normal limits, including aldosterone, cortisol, and catecholamine, metanephrine, VMA levels, and potassium levels.
Division of hepatic lateral attachments allows greater mobilization and aids in exposure. Dissection directly upon the proximal vena cava allows localization of the right adrenal vein. Since the right adrenal vein drains directly into the IVC, options for ligation include GIA, Hem-o-lok clips, or suture ligation. It is important to leave at least 2-3 mm of vein distal to a Hem-o-lok clip to ensure hemostasis. Once the vein is divided, mobilization of the superior aspect of the adrenal gland allows final attachments to the renal upper pole to be released and divided.
Final pathology demonstrated metastatic adenocarcinoma, papillary type. Post-operatively, he developed Addisonian disease, and a cosyntropin ACTH stimulation test was performed, which was positive. He currently is on steroid replacement therapy.
Radical adrenalectomy of a mass greater than 5 cm presents a challenging approach that can be accomplished with robotic assistance.